A 9-year-old boy sustains a minor blow under the right eye. There is almost no bruising, yet he has complete restriction of upward gaze and marked diplopia. CT shows a small linear orbital floor defect with herniation of the inferior rectus through it. The most appropriate management is:

• A Urgent surgical release within 24 to 48 hours ✓
• B Observation with double vision expected to resolve spontaneously
• C Delayed exploration after 3 weeks once oedema settles
• D Botulinum toxin injection into the inferior rectus

Explanation

This is the paediatric white-eyed blowout fracture: green bone springs back like a trapdoor, entrapping the inferior rectus and its nutrient vessels with minimal external signs. Entrapped muscle suffers ischemic necrosis and fibrosis if release is delayed, producing permanent restriction. Unlike adults, where routine repair waits about two weeks for oedema to settle, the trapped-muscle trapdoor pattern in children mandates urgent release within 24 to 48 hours.

Reference: Scott-Brown's Otorhinolaryngology and Head and Neck Surgery, 8th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.